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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST • Type of usiness or Pro rt FACILITY ID # F4<900 23 SERVICE REQUEST # 41 oZ OWNER OPE TOR CHECK if BILLING ADDRESS FACILITY NAME SITE ADDRESS Street Number erection /CGN �' ! 'S // ee a J2' HEW ACCEPTED BY: / HOME or MAILING ADDRESS (If Different from Site Address) Street Number F Street Name CITY STATE ZIP PHONE 1 EXT. APN # SERVICE CODE: 1 LAND USE APPLICATION # PHONE #2 EXT. ( ) Amount Paid"� �'� �m � BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR/jm� IM��'U CHECK If BILLING ADDRESS BUSINESS NAME pHONEI HOME Or MAILING ADD SS 1 FAx i —�/'7 �[ CITY TATE zip BILLING ACKNO DGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this app ' a on and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S A and FEDERAL la APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGE If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thVame time it is provided to me or my representative. PAYMEN A /1 TYPE OF SERVICE REQUESTED: R COMMENTS: COUNN SAN JOAQUW ONMEKTAL H DEPAR M T HEW ACCEPTED BY: / EMPLOYEE #: DATE: G ;0/6S ASSIGNED TO: ) EMPLOYEE #:DATE: Date Service Completed (if already completed): SERVICE CODE: 1 PIE: Z p Fee Amount: Amount Paid"� �'� �m � Payment Date DS Payment Type Invoice # Check # ,_ Received By: